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THE HAITI CASE STUDY Working Paper of the collaborative NATO-Harvard project: TOWARDS A COMPREHENSIVE RESPONSE TO HEALTH SYSTEM STRENGTHENING HARVARD MEDICAL SCHOOL IN CRISIS-AFFECTED FRAGILE STATES NATO JOINT ANALYSIS AND DEPARTMENT OF GLOBAL HEALTH LESSONS LEARNED CENTRE AND SOCIAL MEDICINE 1 HARVARD MEDICAL SCHOOL NATO JOINT ANALYSIS AND DEPARTMENT OF GLOBAL HEALTH LESSONS LEARNED CENTRE AND SOCIAL MEDICINE THE HAITI CASE STUDY Working Paper of the collaborative NATO-Harvard project: Towards a Comprehensive Response to Health System Strengthening in Crisis-affected Fragile States This project was conducted jointly by researchers from Harvard Mecical School – Department of Global Health and Social Medicine and analysts from NATO’s Joint Analysis and Lessons Learned Centre under the sponsorship of NATO’s Allied Command Transformation. Additional funding for this case study was provided by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH. © 2012, Harvard University and NATO Cover art by CDR Monica Allen Perin, US Navy artist with the Navy History and Heritage Command executed on commission for JALLC as US Navy reserve support to NATO © 2012 US Navy All rights are reserved. Images may not be reproduced without the permission of JALLC and the US Navy History and Heritage Command i THE HAITI CASE STUDY 27 June 2012 FOREWORD A joint study team from NATO's Joint Analysis and Lessons Learned Centre, Harvard Medical School, and Harvard Humanitarian Initiative is engaged in an ongoing study project to infer elements of a strategic framework for health system strengthening in crisis-affected fragile states. The joint study team has adopted a multi-case study approach, and it is with great pleasure that we release this working paper documenting the findings from the subject of the first case study: Haiti after the January 2010 earthquake. The paper addresses four key themes: the impact of the earthquake and the subsequent cholera epidemic on Haiti's health system; security community participation in health system recovery and reconstruction; coordination mechanisms that facilitated or directed the security community's involvement; and the information generating and sharing mechanisms that allowed the security community to best participate in health system strengthening. Investigations into these four themes were focussed through the use of the three narratives given in the Annexes to this paper. The outcome of this first case study is a number of key takeaways and food for thought which will inform the research being undertaken by the joint project team as it carries out the subsequent case studies. We trust that this working paper is informative and we look forward to releasing the papers on the future case studies and the final report detailing the overall project findings and Vanessa Bradford Kerry, MD MSc Director of Global Public Policy and Social Change, Department of Global Health and Social Medicine, Harvard Medical School ii ACKNOWLEDGEMENTS PROJECT TEAM Dr. Vanessa Bradford Kerry Cdr. Dr. Christian Haggenmiller Harvard Medical School, German Navy, NATO – JALLC Department of Global Health and Social Medicine Dr. Margaret Bourdeaux Cdr. Luigi Ceppodomo Division of Global Health Equity Brigham and Italian Navy, NATO – JALLC Women’s Hospital Mr. John Crowley LtCdr Andre Thouvenel Harvard Humanitarian Initiative French Navy, NATO – JALLC Capt. Brad Holt, US Navy NATO – Allied Command Transformation CUSTOMER REPRESENTATIVE NATO HQ Supreme Allied Commander Transformation Capability Development Joint Deployment and Sustainment, Medical Branch Col. Toby Rowland, British Army and Col. Dr. Valerie Denux, French Military Health Service ADVISORY BOARD H.E. Ambassador Michel Rentenaar, NATO – Civilian Advisor to the Supreme Allied Commander Europe Rear Adm. Bruce Doll, US Navy, NATO – Medical Advisor to the Supreme Allied Commander Transformation Brig. Gen. Peter Sonneby, Royal Danish Air Force, NATO – Commander JALLC Col. Karlheinz Nickel, German Air Force, NATO – JALLC Prof. Michael Reich, Harvard School of Public Health – Taro Takemi Professor of International Health Policy Dr. Jennifer Leaning, Harvard School of Public Health – Director, FXB Center for Health and Human Rights Dr. Michael Vanrooyen, Director – Harvard Humanitarian Initiative Dr. Frederick Burkle, Senior Fellow – Harvard Humanitarian Initiative Dr. Stewart Patrick, Council on Foreign Relations – Senior Fellow and Director of the International Institutions and Global Governance Program Dr. Stephen Morrison, Center for Strategic and International Studies – Director of the Center on Global Health Policy iii EXECUTIVE SUMMARY An effective comprehensive response to health system strengthening in crisis-affected fragile states demands coherent action by all participating actors. A particularly complex challenge in this regard is coordinating the desired outcomes and the required actions of the humanitarian & development and security communities. A joint team from NATO's Joint Analysis and Lessons Learned Centre and Harvard Medical School is engaged in a study with the overarching aim to infer elements of a strategic framework for health system strengthening in crisis-affected fragile states focusing on optimal use of all global contributions. The approach adopted by the team to meet this aim relies predominantly on case study research. This report documents the results from investigation of the first case study: Haiti. Haiti met all three criteria established for case study selection: it is a fragile state whose health system was threatened by a major earthquake followed by a major cholera outbreak; there was a global crisis response directed towards health system strengthening; and a multinational military force with a peace-keeping/peace-building or stabilization mandate was present. Four key themes are developed: the impact of the earthquake and the subsequent cholera epidemic on Haiti’s health system; security community participation in health system recovery and reconstruction; coordination mechanisms that facilitated or directed the security community’s involvement; and the information generating and sharing mechanisms that allowed the security community to best participate in health system strengthening. Investigations into these four themes were focussed through the use of the three narratives given in the Annexes to this paper. FINDINGS The Haitian government lost significant assets—personnel, infrastructure, communications, records and administrative systems—at a time when their citizens were in the greatest peril and counting on them the most. Additionally, the aid community, including the UN peacekeeping mission MINUSTAH, UN agencies, and aid organizations were also severely affected by the earthquake and were unable to offer robust support of the Haitian state. Nations responded principally by deploying military assets including logistics, security escorts, rubble clearance, engineering services, and tertiary care, all of which contributed significantly to the overall effort of the international community in responding to the earthquake; the US was the largest bilateral responder. A coordination architecture for the whole response existed at the strategic level (High Level Coordination Committee), the operational level (Coordination Support Committee), and at the tactical level (UN sector-based cluster system). The key military tactical level coordination mechanism was the Joint Operations and Tasking Center, formed by UN Office for the Coordination of Humanitarian Affairs, MINUSTAH and other key partners, to orchestrate the use of military assets for relief purposes. The US military created the Humanitarian Assistance Coordination Centre to interface with the Coordination Support Committee and the Joint Operations and Tasking Centre. Coordination among donor nations, the government of Haiti, UN agencies, militaries and relief agencies was a complex web. Personal relationships and friendships among leaders of response entities were instrumental in facilitating coordination mechanisms. iv During both the earthquake and the cholera responses, there were difficulties and missed opportunities in processing and sharing important situation awareness information among all actors, despite considerable efforts to do so. However, new ways and means of collecting, processing and visualizing data—for example, social media, cell phone tracking data, Geographic Information Systems, etc.—show significant potential to improve shared situation awareness. All of the above lead to the overarching finding from this case study: coordination mechanisms and institutional arrangements necessary to undertake a disaster response of this size and magnitude remain underdeveloped and inefficient. TAKEAWAYS As this report represents the first in a series of case studies, no specific recommendations are made. But three takeaways have been identified for consideration by global crisis responders to develop future frameworks for strengthening state health systems: • In an overwhelming, chaotic, disaster situation the security community might be an appropriate contributor to strengthen some elements of the health system: securing the supply chain; contributing to the health service delivery in providing surge secondary and tertiary care to assist health organizations regain their pre-crisis levels of functioning; supporting local and international leadership by providing security to health stakeholders. • Coordination among the key actors from the humanitarian and security
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